Dying patient Last hours of live Transitioning Once transitioning process started, discuss the goals of care with family (may be patient if he is able to) Several patho-physiological changes occur as patient is transitioning Patient develops multiple signs & symptoms as they are getting closer to death The S/S are devastating to patients and staff & friends & family. Control each symptom effectively, May require contineous care, family / friends needs access to patients 24/7 Aggressive resuscitative measure are fruitless The degree of family distress seems to be inversely related to the extent to which advance planning & preparation occurred. Spending time in preparation of families is very worthwhile Physicians, nurses & hospice staff need to have a clear understanding of: signs & symptoms pathophysiology pharmacological / non-pharmacological approach changes encountered surrounding the dying process : Decreasing Appetite/Food Intake, Wasting, Decreasing Blood Perfusion, Renal Failure, Decreasing Level of Consciousness , Terminal Delirium, Loss of Ability to Swallow,Pain, declining in all aspects of life Weakness/Fatigue : functional decline Decreasing Fluid Intake, Dehydration Neurological Dysfunction: An Overview Loss of Sphincter Control Changes in Respiration Loss of Ability to Close Eyes Manage other s/s Most common S/S are: functional decline, dependent on all ADLs, anxiety, dyspnea, delirium, death rattle, nausea, worsening of discomfort / pain. Place of death: * 59-81% wants to die at home. * 20% of dying patients are having rough time due to transition between hospital / home/ nursing home/ assisted living facilities. *Recognize transitioning and help them die peacefully at home *45% of deaths occur under hospice care in USA * Place of death of hospice patients : at home 42%, at nursing home 18%, assisted living 7%, hospice in patient were 26%, hospital 7.4% Weakness/Fatigue : S/S: Increases generalized weakness, more tired, sleepy, may be confused Falls, injuries Consider AIDS: cane, walker, wheelchair, bedside commode etc. Unable to move even in the bed Pain : joints, muscles, nerves pressure ulcer, Trouble eating, drinking Incontinent Rx Stop chasing fatigue (irreversible) Consider AIDS: cane, walker, wheelchair, bedside commode etc. Passive range of movements Q1-2 hrs Prevent pressure ulcer : Intermittent massage before and after turning to areas of contact with bed Do not massage: erythematous areas, skin breakdown, wounds, pressure ulcers. Turn him from side to side Q 1 to 2 hours Protect bony prominence with hydrocolloid dressings & special soft supports Use a draw sheet to minimize pain & shearing forces to the skin When turning becomes painful: use pressure-reducing surface with soft pillows, air mattress / soft bed. Decreasing Appetite: Almost all of them lose their appetite, decreased intake as death approaches Wasting The causes are irreversible Wrong: “starve to death” stop feeding is seen as “giving in” “loosing hope” Not being hungry is normal at this stage. Food: not appealing or may be nauseating The patient would likely eat if he or she could Clenching of teeth may be the only way for the patient to express desires Parenteral or enteral feeding : no help: Multiple studies demonstrate that they do not help. (neither improves symptom control nor lengthens life nor are they beneficial) Anorexia may be protective, as the resulting ketosis can lead to a greater sense of well being & diminish pain Food pushed upon the unwilling patients may be problematic (e.g., aspiration) Help care givers to find alternate ways to provide appropriate physical care & emotional support to the patient so that they can continue to participate & feel valued during the dying process Dehydration : Most patients also reduce their fluid intake, or stop drinking entirely, long before death If they are still able to drink but are not eating, salty fluids such as soups, soda water, sport drinks may maintain electrolytes, decrease nausea, Whereas onlookers’ distress but patients are euphoric (endorphins) Rx This is an expected event. Most experts feel that dehydration at this stage “does not cause distress” Dehydration may stimulate endorphin release that adds to the patient’s sense of well being Hypotension / feeble pulse is part of the dying process, not an indication of dehydration Patients who are not able to move in the bed do not get light-headed or dizzy, no orthostasis Patients with peripheral edema or ascites have excess body water & salt and are not dehydrated Consider sub Q or hypodermoclysis : if the goal is to reverse delirium IV fluids : cumbersome, painful, uncomfortable, maintenance issues, changing, poor veins Fluid overload results in peripheral or pulmonary edema, with significant hypoalbuminemia Worsened breathlessness, cough, orotracheobronchial secretions, potential to prolong the dying process an undesirable side effect Dehydration: Mucosal/Conjunctival Care Even in the face of dehydration, maintain moisture in mucosal membranes with meticulous oral, nasal & conjunctival hygiene to comfort and minimize the sense of thirst Moisten & clean oral mucosa Q 15 to 30 minutes with either baking soda mouthwash (1 teaspoon salt, 1 teaspoon baking soda, 1 quart tepid water) or an artificial saliva preparation to minimize the sense of thirst and avoid bad odors or tastes & painful cracking Treat oral candidiasis with topical Nystatin or oral Fluconazole 200 mg then 100 mg /d for a week (if able to swallow) Coat lips & anterior nasal mucosa hourly with a thin layer of petroleum jelly to reduce evaporation & dryness Avoid perfumed lip balms and swabs containing lemon and glycerin, as these can be both desiccating & irritating, particularly on open sores Eyelids open: use ophthalmic lubricating gel Q 3 to 4 hours, or artificial tears or physiological saline Q 15 to 30 minutes to avoid painful dry eyes Decreasing Blood Perfusion, Renal Failure : Diminished peripheral blood perfusion due to lack of intake S/S : Tachycardia, Hypotension, Peripheral cooling, skin Mottling (livedoreticularis), Venous blood may pool along dependent skin surfaces, oliguria or Anuria Parenteral fluids are useless: causes fluid retention, overload, congestion, increase urination Neurological Issues surrounding terminal phase: Nonreversible factors: Hypoxemia, Metabolic imbalance, Acidosis, accumulation of toxins due to liver and renal failure, Adverse effects of medication, Sepsis, Disease-related factors, Reduced cerebral perfusion, coma Assume that all unconscious patient can hear everything. While we do not know what unconscious patients can actually hear, experience suggests that at times their awareness may be greater than their ability to respond Advise caregivers to talk to the patient as if he is conscious & can understand Include the patient in the conversations Create an environment that is familiar & pleasant Surround the patient with loved ones : the people, children, pets, things, music, that he would like Encourage family to say the things they need to say Occasionally it may seem that he may be waiting for permission to die Ecourage caregivers to give the patient permission to “let go” & die in a manner that feels most comfortable to them Caregivers / families verbalize “I know that you are dying, please do so when you are ready” Do not assume patients knows the person, they need to verbalize loud enough : “I love you. I will miss you. I will never forget you. Please do what you need to do when you are ready” If child: “Mommy and Daddy love you. We will miss you, but we will be OK” It is ok to touch, massage & lie next to patients, “two roads to death” The “usual road” most common, presents with decreasing level of consciousness leading to coma and peaceful death The “difficult road” Terminal Delirium: a few present with agitated delirium secondary to CNS excitation, irritability, agitation, delirious, with or without myoclonic jerks that leads to coma, and death. Partial or Grand Mal seizures could occur (particularly with cerebral metastases) “usual road to death” S/S : Decreasing Level of Consciousness in majority of patients, increasing drowsiness, sleep most if not all of the time, and eventually become unarousable, Absence of eyelash reflexes on physical examination indicates a profound level of coma equivalent to full anesthesia. Finally dies peacefully. Rx : Plan ahead to reduce family distress due to their decreasing ability to communicate, feed, feelings loosing hope, losing a loved one, most of us wants to communicate with their loved one. Terminal Delirium: Restlessness & delirium may be the first sign to herald the “difficult road to death“ Impaired level of consciousness, confusion, restlessness, and/or agitation, moaning, groaning, irritation, restless, appears to be suffering, with or without day-night reversal, this can accompany the dying process Agitated terminal delirium can be very distressing to all involved in the care Never let terminal delirium goes misdiagnosed or improperly managed (horrible death with terrible pain & suffering) Everybody involved worry that their own death will be the same Rx : educate and support everybody around the patient to understand dying process That what the patient experiences may be very different from what onlookers see Treat underlying causes only if death is not imminent If delirium presents and the patient is not perceived to be actively dying, it may be appropriate to evaluate and try to reverse treatable conditions However, if the patient is close to the last hours of his life, then do comfort care only If death is imminent, it will not be possible to reverse the underlying causes. Focus on the management of the symptoms associated with the terminal delirium Help the patient & family so they settle down Check for pain, fecal impaction & urinary retention, uncomfortable position, Medicating for Delirium Neuroleptics Haloperidol (0.5–2.0 mg q 1 hr prn once settled q6 hrs ) given PO, bucal, skin, rectal subcutaneously (max 30 mg/d but up to 100 mg/d have been used) Chlorpromazine (Thorazine) (10–25 mg PO q hs to q 4-6 hrs to start and titrate), po or rectally, it is a more sedating (up to 800 mg/d) 2. Benzodiazepines are used widely as they are anxiolytics, amnestic, skeletal muscle relaxants, & antiepileptic. use in alcohol or drug withdrawal, drug induced, seizures. use cautiously Lorazepam (Ativan) 1–2 mg as an elixir or the tablet pre dissolved in 0.5–1.0 ml of water and administered, against the buccal mucosa q 1 h prn will settle most patients with 2–10 mg/24 hours. Once settled then give q 3–4h to keep the patient settled For a few extremely agitated patients, high doses of Lorazepam 20–50+ mg/24 hours, may be required A Midazolam (Versed) infusion of 1–5 mg SC or IV q 1h, preceded by repeated loading boluses of 0.5 mg q 15min titerate to effect, may be a rapidly effective alternative Neuroleptic medications may be required to control delirium for patients for whom benzodiazepines prove excitatory and not have the desired settling effect Antiepileptics : Seizures may be managed with high doses of benzodiazepines, Diazepam 10 mg suppository prn q 4-12 hrs. Other antiepileptics such as phenytoin PR or IV, Fosphenytoin SC, or phenobarbital 60–120 mg PR, IV, or IM q 10–20min prn may become necessary until control is established Use Opioids with Caution : When moaning, groaning, and grimacing accompany agitation and restlessness, they are frequently misinterpreted as pain Myth : that pain suddenly develops during the last hours of life when it has not previously been out of control While a trial of opioids may be beneficial in the unconscious patient who is difficult to assess, physicians must remember that opioids may accumulate and add to delirium when renal clearance is poor If the trial of increased opioids does not relieve the agitation or makes the delirium worse by increasing agitation or precipitating myoclonic jerks or seizures (rare), then pursue alternate therapies directed at suppressing the symptoms associated with the delirium Changes in Respiration: Changes in a dying patient’s breathing pattern may be indicative of significant neurological compromise Breaths may become very shallow and frequent with a diminishing tidal volume Periods of apnea and/or Cheyne-Stokes pattern respirations may develop Accessory respiratory muscle use may become prominent A last reflex breaths may signal death Families and professional caregivers may frequently ask: will he be suffocated ? The most distressing signs of impending death is that the comatose patient will experience a sense of suffocation The unresponsive patient may not be experiencing breathlessness or “suffocating” Oxygen may actually prolong the dying process Rx: Low doses of opioids or benzodiazepines are appropriate to manage any perception of breathlessness Loss of Ability to Swallow: In the last hours of life, weakness & decreased neurological function frequently impair the patient’s ability to swallow The reflexive clearing of the oropharynx decline & secretions from the tracheobronchial tree accumulate These conditions may become more prominent as the patient loses consciousness Buildup of saliva and oropharyngeal secretions may lead to gurgling, crackling or rattling sounds with each breath Some have called this the “death rattle” (a term we want to avoid) For unprepared families and professional caregivers, it may sound like the patient is choking Rx: Once the patient is unable to swallow, stop all oral intake Warn families and professional caregivers of the risk of aspiration Reduce saliva and secretion production Use of medications to reduce saliva: the earlier treatment is initiated, the better it works, as larger amounts of secretions in the upper aerodigestive tract are more difficult to eliminate However, premature use in the patient who is still alert may lead to unacceptable drying of oral & pharyngeal mucosa Recommended medications and dosages include: Atropine: 4 drops in the beginning the 1-2 drops q1-4 hrs (cardiac / CNS excitation) Scopolamine 0.2–0.4 mg SC q 4 h or 1–3 transdermal patches q 72h or 0.1–1.0 mg/h by continuous IV or SC infusion Glycopyrrolate (Robinul) 0.2 mg SC q 4–6 h or 0.4–1.2 mg/day by continuous IV or SC. 1-2 mg tab q 8 hrs prn Use repositioning to clear accumulated fluids If excessive fluid accumulates in the back of the throat and upper airways, it may need to be cleared by repositioning the positioning or postural drainage Turning the patient onto one side or a semiprone position may reduce gurgling Lowering the head of the bed and raising the foot of the bed while the patient is in a semi-prone position may cause fluids to move in the oropharynx from which they can be easily removed, maintain only for few minutes at a time as stomach contents may also move unexpectedly in to oropharynx Avoid suctioning, Oropharyngeal suctioning is not recommended Fluids / food are ineffective, could be dangerous Suctioning may have only undesirable effects, such as: stimulating a peaceful patient or distressing for family members who are watching Loss of Sphincter Control: Fatigue and loss of sphincter control in the last hours of life may lead to incontinence of urine and/or stool Both can be very distressing to patients and family members, particularly if people are not warned in advance that these problems may arise Loss of Sphincter Control: Management If incontinence occurs, attention needs to be paid to cleaning and skin care A urinary catheter may minimize the need for frequent changing and cleaning to prevent skin breakdown Reduce the demand on caregivers However, catheterization is not always necessary if urine flow is minimal and can be managed with absorbent pads or surfaces If diarrhea is considerable and relentless, a rectal tube may be similarly effective Pain: Signs and Symptoms While many fear that pain will suddenly increase as the patient dies, there is no evidence to suggest this occurs Though difficult to assess, continuous pain in the semiconscious or obtunded patient may be associated with: Grimacing and continuous facial tension, particularly across the forehead and between the eyebrows Physiologic signs, such as transitory tachycardia, that may signal distress Do not over-diagnose pain when fleeting forehead tension comes and goes with movement or mental activity (e.g., dreams or hallucinations) Do not confuse pain with the restlessness, agitation, moaning, and groaning that accompany terminal delirium If the diagnosis is unclear, a trial of a higher dose of opioid may be necessary to judge whether pain is driving the observed behaviors Pain: Knowledge of opioid pharmacology becomes critical during the last hours of life The liver conjugates codeine, morphine, oxycodone, and hydromorphone into glucuronides Some of their metabolites remain active as analgesics until they are renally cleared, particularly morphine As dying patients experience diminished hepatic function and renal perfusion, and usually become oliguric, anuric, routine dosing or continuous infusions of morphine may lead to: Increased serum concentrations of active metabolites, Toxicity, Increased risk of terminal delirium Discontinue routine dosing Titrate morphine breakthrough (rescue) doses to manage expressions suggestive of continuous pain. Consider the use of alternative opioids with inactive metabolites, Fentanyl, Hydromorphone Morphine neurotoxicity : Loss of Ability to Close Eyes: Advanced wasting leads to loss of the retro-orbital fat pad, and the orbit falls posteriorly within the orbital socket As eyelids are of insufficient length to both extend the additional distance backward and cover the conjunctiva, they may not be able to fully appose This may leave some conjunctiva exposed even when the patient is sleeping Eyes that remain open can be distressing to people unless the reason is understood If conjunctiva remains exposed, maintain moisture by using ophthalmic lubricants, artificial tears, or physiological saline as previously discussed Changes in Medication Needs : This is it. This is terminal event. No point of return. Involve the whole team. As patients approach the last hour of their lives, reassess the need for each medication and minimize the number of meds that the patient is taking Use only those medications which are essential to manage symptoms such as pain, breathlessness, excess secretions, meds needed for terminal delirium & reduce the risk of seizures Choose the least invasive route of administration: The buccal mucosa or oral routes first; then rectal ; then subcutaneous or intravenous routes only if necessary Never use intramuscular injections communication is very important so keep communicating with the family members what ever you would do.